THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

Effective Date: January 1, 2004

Purpose: Federal law requires Open MRI of Wausau (Open MRI of Wausau) to inform its patients about the ways that Open MRI of Wausau may use and disclose your protected health information. In addition, federal law requires Open MRI of Wausau to inform patients of your rights regarding disclosures of your health information.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

Open MRI of Wausau may use and disclose protected health care information without your consent or authorization in certain circumstances. State and federal law allow Open MRI of Wausau to use/disclose your protected health information for purposes of treatment, payment, health care operations, and in other defined circumstances as well. Except in treatment circumstances, Open MRI of Wausau will make efforts to limit the information used or disclosed to that which is minimally necessary. Following are a listing of these circumstances and examples of uses and disclosures to assist your understanding of our privacy practices.

Treatment: Open MRI of Wausau will use your protected health information in order to treat you, to facilitate appropriate transfer of information to consulting specialists or other referral sources of health care (e.g., the hospital, primary care physicians or surgical centers), and to ensure continuity of care and coordinate your health care through case management.

Payment: Open MRI of Wausau will use and disclose your health information to send bills and to collect payment from you, your insurance company and other third-parties for services you have received from Open MRI of Wausau.

Health Care Operations: In order to ensure quality care for our patients, Open MRI of Wausau engages in numerous health care operations. These health care operations include, but are not limited to:

· Care management and case coordination
· Guideline and protocol development
· Administrative and business management activities
· Business planning and development
· Training, accreditation, certification, licensing or credentialing
· Health care improvement and quality management programs
· Health care cost-reduction programs
· Legal and accounting services
· Medical review and auditing

Federal, State of Local Law: Open MRI of Wausau will disclose your protected health information when required to do so by state, federal or local law.

Public Health Policy: Open MRI of Wausau will disclose your health information to public health departments and agencies if required to do so by law.

Organ and tissue donation: If needed, Open MRI of Wausau may disclose protected health information to relevant organization to facilitate organ and tissue donation and transplantation.

Research: Open MRI of Wausau sometimes participates in research studies for new treatments and would share protected health information with the research organization. In these circumstances, any Open MRI of Wausau patient participating in the research study would sign a separate consent to be in the study and to share specific health information.

Circumstances of Serious and Imminent Threat to Health or Safety: If there is a serious and imminent threat to your health or safety or the health or safety of the public or another person, Open MRI of Wausau may disclose your protected health information.
Victims of Abuse or Neglect: Open MRI of Wausau will notify the appropriate government authority if Open MRI of Wausau believes a patient has been the victim of abuse or neglect.

Coroners and Medical Examiners: Open MRI of Wausau may disclose information to a coroner or medical examiner to assist with determining the cause of a death.
Health Oversight Activities: Open MRI of Wausau may disclose protected health information to certain health oversight activities authorized by law including audits, investigations, accreditations, licensure or disciplinary activities.

Worker’s Compensation: Open MRI of Wausau may disclose your medical records to worker’s compensation departments for the benefit of treatment and case management of work-related injuries.

Judicial Proceedings: Open MRI of Wausau may release protected health information in response to a court order.

Government Functions: In some circumstances, Open MRI of Wausau can disclose your protected health information for specific government activities. Examples of these include:

· Inmates and Law Enforcement Custody: If you are an inmate, Open MRI of Wausau may disclose medical information to the correctional institute or law enforcement as necessary.

· Medical Suitability Determinations: Open MRI of Wausau may disclose your protected health information to the Department of State for use in making medical suitability determinations.

· Military and Veterans: If you are a member of the armed forces, Open MRI of Wausau may disclose your protected health information to the government to facilitate military missions.

· National Security and Intelligence: If authorized by law, Open MRI of Wausau may disclose your protected health information for intelligence, counter-terrorism and national security activities.

· Protective Services for the President and Others: In order to provide protection to the president or foreign heads of state, Open MRI of Wausau may need to disclose your protected health information, only if authorized by law.

DISCLOSURES THAT YOU MAY OBJECT TO

Unless you object, Open MRI of Wausau may also use or disclose limited medical information in the following situations:

· Open MRI of Wausau may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

· Open MRI of Wausau currently does not use your health information for fundraising purposes. If Open MRI of Wausau chose to use your information for fundraising, Open MRI of Wausau would get your approval for this disclosure prior to any release of information.

· Open MRI of Wausau currently does not use your information for external marketing purposes and will not use any health information for marketing unless you have given specific consent for this disclosure. Please see the Marketing Policy for full details.

· Open MRI of Wausau will release medical information to a family member or friend regarding your condition only as you specifically designate and have consented to. This is fully detailed in the Facility Directory Policy.

Any other uses or disclosures will be made only with your written authorization and you may revoke this authorization in writing at any time. Open MRI of Wausau requests that you use our Authorization for Release of Medical Information and our Revocation of Authorization to Release Medical Information forms for these purposes.

Patient Rights Regarding Protected Health Information

As a patient, you have numerous rights regarding how your protected health information is used. Your rights include the following:

1. You have a right to request that we restrict our uses and disclosures of protected health information. For example, Open MRI of Wausau will permit a patient to request that it restrict uses or disclosures of protected health information about the patient to carry out treatment, payment or health care operations; disclosures of protected health information directly relevant to the involvement of a family member, personal representative or another person responsible for the care of the patient; or to entities involved in disaster relief purposes. The circumstances in which you can request restrictions are detailed in the Policy for Requesting Restrictions of Protected Health Care Information. It is important to understand that Open MRI of Wausau is not required to agree to requests for restrictions.

2. You have a right to receive communications that contain protected health information at alternative locations or by alternative means. For example, patients may request that Open MRI of Wausau contact them at work for appointment reminders rather than at home provided that the patient provides Open MRI of Wausau with his or her work contact number. However, Open MRI of Wausau will not honor a request for alternative contact methods unless the patient provides sufficient alternative address or contact information. These are detailed in the Policy for Requesting Restrictions of Protected Health Care Information.

3. You have the right to inspect and copy your protected health information. Open MRI of Wausau requests that you use the Authorization for Release of Medical Information form when exercising this right. Open MRI of Wausau may charge a reasonable fee for the costs of copying, mailing or preparing summary information that responds to your request. You should know that in certain limited circumstances, the law allows Open MRI of Wausau to deny your request to inspect and copy your records. The full policy and procedures regarding this are detailed in the Policy on Individual Access to Protected Health Information.

4. You have the right to have changes made to your protected health information if you feel it is inaccurate. Open MRI of Wausau requests that you use our Request for Amendment of Health Information form to request these changes. Open MRI of Wausau will review your request and make the changes if we believe they are appropriate. Open MRI of Wausau will also distribute these changes to health care providers that you ask be made aware of the change or to others we believe should know of the change. Under some circumstances, Open MRI of Wausau may deny your request for an amendment to your protected health information. Open MRI of Wausau will provide a written response to your request for an amendment and in this response will provide detailed information on how you may review the changes or appeal the denial. Your right to amend health care information is fully detailed in the Patient Request To Amend Medical Records Policy.

5. You have a right to receive an accounting of our disclosures of your protected health information by Open MRI of Wausau. This accounting will not include disclosures of your health information made for treatment, payment or health care operations. Open MRI of Wausau requests that you use the Request for Accounting of Protected Health Information form to receive this log. Your request must specify a time period for the accounting, which may be no longer than six years. Open MRI of Wausau will provide the first accounting to you in any 12-month period free-of-charge. After this, Open MRI of Wausau may charge a fee but we will notify you of the fee before we process the request. You have the right to withdraw your request once you have learned that your request will require you to pay a fee. The full details of our policy and procedures for receiving a log of disclosures of your protected health information and the circumstances in which disclosures will not be provided in the accounting is described in the Policy on Accounting of Disclosures of Protected Health Information.

6. You have a right to receive a paper copy of this Privacy Notice at any time. If you have received an electronic version of this Privacy Notice you may also request a paper copy. Paper copies are available through Reception or may be printed from our web site. You may call or write Reception at: Open MRI of Wausau, Weston Clinic Building . Suite 120
4005 Community Center Drive, Weston, WI 54476, 715-847-2020 or 1-888-616-5611

Distribution and Revision of the Privacy Notice

Open MRI of Wausau is required by federal law to maintain the privacy of protected health information and to provide patients with notice of its legal duties and to abide by the terms of this Privacy Notice. Open MRI of Wausau will distribute this privacy notice to all patients who request one on or after the effective date. Open MRI of Wausau will post the notice in a clear and prominent location in all of its offices and on its web site. Open MRI of Wausau will provide the Privacy Notice via email to any requesting patient who agrees to an electronic notice. Open MRI of Wausau patients may, at any point, withdraw their agreement to an electronic Privacy Notice. Any patient who receives an electronic Privacy Notice may also obtain a paper copy if requested.

Open MRI of Wausau is allowed to make revisions to the Privacy Notice. If revisions are made, the notice of these revisions will be distributed to current patients of Open MRI of Wausau within 60 days of a revision as well as information on how to obtain a copy of the revised Privacy Notice.